Code of Conduct

CODE OF CONDUCT

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT WHO SHOULD READ THE CODE?

All members of the NYU Langone Community—trustees, officers, faculty, full- and part-time employees, medical staff, students, residents, fellows, volunteers, trainees, consultants, vendors, contractors and agents of NYU Langone—are expected to follow the rules and regulations outlined in this Code of Conduct (the “Code”) and should familiarize themselves with the Code in its entirety.

WHO IS COVERED UNDER NYU LANGONE?

Any reference to “NYU Langone” in this Code refers to NYU Langone Health System (the “Sys- tem”); its subsidiary, NYU Hospitals Center (“NYUHC”), which includes Tisch Hospital, Perlmutter Cancer Center, NYU Lutheran, NYU Hospital for Joint Diseases, NYU Cobble Hill, Hassenfeld Chil- dren’s Center and affiliated ambulatory sites; affiliates of the System; and the New York University School of Medicine (“NYUSOM”), an administrative division of New York University; and NYUSOM affiliates. For purposes of this Code, “affiliate” means an entity under the direct or indirect control of the System or NYUSOM, whether now existing or hereafter created. The Code also has been adopted by the NYU Lutheran Family Health Center; therefore, for the purposes of this Code, “NYU Langone” also includes the NYU Lutheran Family Health Centers.

This Code is not a contract of employment nor does it create any rights or expectations regarding continued employment or benefits at NYU Langone. All employment is deemed at-will (i.e. can be terminated by the employee or NYU Langone at any time, with or without cause) unless a written contract of employment exists setting forth a specific duration and executed by an authorized NYU Langone signatory. Notwithstanding the statements in this Code, NYU Langone remains free to appeal, modify, or amend the Code, and to change wages, benefits, and all other working conditions, without prior notice.

NYU Langone Health System 2016 printing

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT TABLE OF CONTENTS

Introduction • Letter from the Dean & CEO 1 • NYU Langone’s Mission & Values 2

Standards of Conduct with Patients & Colleagues • Foundation Statement – Your Personal Commitment 3 • Quality of Care – Commitment to our Patients 3 • Conduct with Patients and Colleagues 5 • Emergency Care (EMTALA) 6 • Pharmaceuticals, Prescription Drugs, and Controlled Substances 7 • Environmental Health and Safety 7

Complying with Laws, Regulations, & Policies • Laws, Regulations, and NYU Langone Health System Policies 8 • Responsibilities of Managers and Supervisors 9 • Anti-kickback and Physician Self-Referral 10 • Accurate and Truthful Documentation 10 • Investigations, Accreditations, Surveys, Audits, or Inquiries 11

Safeguarding Patient & Other Confidential Information • Confidentiality and HIPAA Privacy 12 • Protection and Use of NYU Langone’s Assets 13 • Political Participation 14

Relationships with Vendors, Consultants, & Other Outside Entities • Conflicts of Interest 15

Research Integrity & Responsible Conduct • Scientific and Clinical Research 16

Reporting Concerns & Enforcement • Responsibility to Report 18 • NYU Langone Health System’s Non-Retaliation Policy 19 • Disciplinary Action 19

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT LETTER FROM THE DEAN & CEO

Dear Colleague, you are also required to familiarize yourself with

As dean and CEO of the recently formed NYU Langone Health System, I am proud to introduce our new Code of Conduct (the “Code”). The new NYU Langone Code is just one of the many great outcomes derived from the innovative partnership between NYU Langone Medical Center, which includes NYU School of Medicine, and NYU Luther- an Medical Center, NYU Lutheran Family Health Centers, and its affiliates. This Code of Conduct is a key element of NYU Langone’s Corporate Com- pliance Program. It supports our mission, values, and policies to promote conduct that is honest, ethical, and lawful. It is important that you understand your personal obligations under this Code. this Code on at least an annual basis. Additionally, it is your responsibility to report any matters you The NYU Langone and NYU Lutheran partnership believe to be a violation of the Code, federal, state, is at the core of our Community Service Plan to or local laws and regulations, or NYU Langone provide high-quality, patient-centered primary and policies. If you become aware of such matters, you specialty care in neighboring communities and to should immediately report it to your supervisor, address an evolving healthcare environment. the NYU Langone confidential Compliance Help- line at 866.NYU.1212, via the online Compliance Equally important is our long-standing commit- intake form, or the Office of Compliance directly. ment to demonstrating the highest level of ethical We will not tolerate any retaliation against you for and legal conduct and daily decision-making when reporting any compliance concerns in good faith. interacting with our patients, our colleagues, our community, and our business partners. Our new As you read through this Code, you will see that Code explains this commitment in greater detail compliance is the responsibility of every member and provides guidance on how to make ethical of the NYU Langone Community. Collectively, it decisions that are reflective of our core principles. takes each of us to achieve the standards set forth This Code applies to every member of the NYU in this Code. I am asking each of you to join me Langone Community: trustees, officers, faculty, full- in making a personal commitment to uphold this and part-time employees, medical staff, students, Code of Conduct without exception. residents, fellows, volunteers, trainees, consultants, vendors, contractors, and agents of NYU Langone. Sincerely, Robert I. Grossman, MD While the Code is comprehensive, it cannot cover every situation you might encounter. It’s up to each individual to seek advice when faced with a question about any of the principles of this Code. Dean and Chief Executive Officer As a member of the NYU Langone Community,

1 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT NYU LANGONE MISSION & VALUES

The mission of NYU Langone is to serve, to teach, Values and to discover. We are committed to making world- We have set the standard for patient care, scientif- class contributions that place service to human ic research, and medical education. We have built health at the center of an academic culture devoted a tradition of service that has touched the lives to excellence in research, patient care, and education. of countless people in New York City, across the We shall provide the facilities and personnel neces- country, and around the world. Our strength as an sary to carry out these functions in the most profes- institution is based on the individual acts and the sional manner possible, and in all activities, we shall spirit of dedication of our physicians, healthcare maintain the highest standards of excellence and professionals, scientists, employees, and students. consideration for the dignity of the individual. To ensure that we remain at the forefront of the Education medical profession and a place where people can In educating the physician, we shall merge the best build successful careers, we have adopted a set traditions of the past with the most relevant content of values that are designed to reflect not only our and vital teaching methods of the present. Our goal is history, but also our commitment to the future. The to instill in each student a respect for his or her pro- values are meant to complement, not replace, our fession and the people he or she serves, to provide for existing codes of ethics and professional responsi- the continuing education of physicians throughout bilities. They are intended to be used as a means to their careers, and to foster an atmosphere of learning enhance the way we deliver services to our pa- for all staff throughout NYU Langone. tients, their families, visitors, and our colleagues.

Research We believe the five values—Performance, Re- We shall stimulate research into the fundamental spect, Integrity, Diversity, and Excellence—will basis of life processes, as well as the nature of dis- enable us to build on our tradition of service, to eases and disorders and the means by which they foster a culture of collaboration and teamwork, can be overcome. We shall encourage collaboration and to better meet the needs of those we serve. among independent researchers, interpret the value of research to patients and the general public, and • Performance – Accountable, responsible, and foster a spirit of inquiry throughout NYU Langone. dedicated to learning and growing professionally by collaborating with one another. Patient Care • Respect – Communicates openly and profes- We shall place the patient at the center of all sionally, shares resources, listens to one anoth- efforts. In providing direct patient care, we shall er, and recognizes one another’s contributions. serve patients from metropolitan New York and • Integrity – Fosters a culture of the highest those referred from other areas of the nation and ethical standards, trust, and honesty. the world. We shall provide professional care and • Diversity – Creates a community of cultural treatment for patients in accordance with high competence and opportunity by embracing a wide standards of medical service, offer programs of breadth of resources, skills, ideas, and knowledge. health education, and maintain a climate in which • Excellence – Passionate about promoting qual- each member of the healthcare team can learn ity, innovation, and safety to achieve world-class and carry out his or her responsibilities in the patient care, education, and research. most professional manner possible.

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 2 FOUNDATION STATEMENT — YOUR PERSONAL COMMITMENT

All members of the NYU Langone Community are • Consider the consequences before acting. If expected to make decisions that are guided by you are asked to do something that you believe principles of honesty, integrity, high ethical stan- may be a violation of this Code, you should seek dards, and a personal commitment to: advice from the Office of Compliance directly, or • Maintain honesty and act in good faith in all via the confidential Compliance Helpline or online aspects of your job. This includes: Compliance intake form, Human Resources, or the - Not making false or misleading statements; Office of Legal Counsel as described on page 18. - Not falsifying or altering data; and • Notify your supervisor of any mistakes you - Not manipulating or concealing information make as soon as they are identified. Covering that is essential for conducting investigations up a mistake is a serious matter that could lead or work-related activities. to disciplinary action.

QUALITY OF CARE — COMMITMENT TO OUR PATIENTS

We are committed to providing high-quality, com- cedures that you do not understand; passionate, skilled patient care in a safe and healing • Courteously and professionally assist pa- environment. Everyone, even those not working tients and visitors in person, on the phone, directly with patients, has a responsibility to: and by other means of communication; • Provide patients with care that is medically • Protect the confidentiality of patients. The necessary, appropriate to the situation, safe, Protected Health Information (PHI) of patients and in compliance with professionally recog- should only be used or disclosed for treatment, nized standards of care; payment, or business purposes as permitted • Involve patients in decisions regarding their care; under HIPAA laws and regulations; • Adhere to infection prevention and control • Assist patients in communicating compliance practices; or quality of care-related issues to the Office • Maintain complete and accurate records of of Patient Relations or to the Compliance Office patient information that fulfill the requirements directly or via the confidential Compliance of NYU Langone policies, accreditation stan- Helpline or online Compliance intake form, as dards, and applicable laws and regulations; described on page 18; • Identify opportunities to improve service and • Inform management of any issues that may quality of care; interfere with your ability to fulfill your profes- • Ensure every patient receives important sional responsibilities; information about their rights, including but • Report patient care incidents and issues not limited to the documents, Your Rights as that do not appear to meet, or that violate a Hospital Patient in New York State, and the NYU Langone’s standards of quality. You Notice of Privacy Practices; should report such violations to your supervi- • Maintain current credentials, expertise, sor, the Compliance Office directly or via the education and training, and competence to confidential Compliance Helpline or online provide patient care; Compliance intake form as described on page • Seek clarification from your supervisor about 18, or if appropriate, to the Centers for Medicare any duties or NYU Langone policies and pro- and Medicaid Services, The Joint Commission,

3 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT New York State Department of Health, or other - Hospitals—Minimum Standards (New York regulatory agency. We will not take disciplinary State Public Health Law) action if you report a concern in good faith; - Standards and Surveys of The Joint Com- • Take pride in your job and do it to the best of mission (including Standards for Long Term your ability. Every member of the NYU Lan- Care), Commission on Accreditation of gone Community contributes to our success, Rehabilitation Facilities, College of American our mission, and our ability to provide quality Pathologists, Accreditation Council for Grad- patient care, cutting-edge research, and educa- uate Medical Education, and other accredit- tion to future physicians; and ing/certifying agencies • Fulfill your personal responsibilities to report - Requirements for accreditation by the Liaison quality measures. You should promptly and Committee on Medical Education (LCME) efficiently fulfill your responsibilities regarding - Standards adopted by the Magnet Recog- compliance with, but not limited to, the standards nition Program, recognizing excellence in provided below. Members of the NYU Langone nursing service Community working in extended care and re- - Consensus measures of the National Quality habilitation, senior housing, adult day care, child Forum day care, and other community service facilities - Principles of the Leapfrog Group for Patient should follow applicable standards for the specif- Safety ic patient, client, or resident populations. - Recommendations and guidelines issued by - Conditions of Participation for Hospitals (Cen- other regulatory and voluntary groups iden- ters for Medicare and Medicaid Services) tified as appropriate by NYU Langone

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 4 CONDUCT WITH PATIENTS, COLLEAGUES, & OTHERS

NYU Langone’s values should guide us in our Patient Care and Nursing Standards, and the relationships with patients and their families, Administrative Policy and Procedures Manual). visitors, colleagues, vendors, and with whomever • Not engaging in disruptive behavior. Disruptive we do business. We need every member of the behavior is any inappropriate behavior, confron- NYU Langone Community’s commitment to: tation, or conflict, ranging from verbal abuse to • Strive to create the best possible experience physical, sexual, or other forms of harassment for our patients, their families, and visitors. that interfere with an individual’s ability to carry • Take the initiative to find safe, creative, and out his/her responsibilities. Examples of disrup- effective solutions to patient-related concerns. tive behavior include but are not limited to: • Maintain positive work relationships with col- - behavior that is abusive, angry, belligerent, or leagues, vendors, and others with whom we intended to publicly humiliate the individual do business. You should demonstrate respect - public comments about lack of competence for your colleagues by communicating positive- in front of patients and or colleagues ly with them and about them, and treating them - yelling, cursing, and/or tirades with dignity in your interactions. - abusive or hostile verbal or physical mistreat- • Treat each person respectfully, as a unique ment of others such as but not limited to insult- individual. NYU Langone will not tolerate ing, teasing, mocking, degrading, or ridiculing discrimination against or harassment of anyone - repeated unprofessional written comments on the basis of race, color, religion, sex, sexual - throwing items or slamming doors orientation, gender and/or gender identity or - systematic belittling of individuals or repeat- expression, marital or parental status, national ed initiation of negative comments instead of origin, ethnicity, citizenship status, veteran or addressing with supervisory personnel military status, age, or disability. - any behavior that fails to support a culture of • Comply with NYU Langone policies on maintain- safety ing an alcohol-, drug-, and smoke-free workplace. • Support and promote a positive work envi- • In addition to this Code of Conduct, follow the ronment, free from disruptive behavior by: specific guidelines on conduct outlined in the - promoting respectful, courteous, and colle- manual and documentation applicable to your gial relationships with all position in the NYU Langone Community (i.e., - encouraging the reporting and investigation Faculty Handbook, Residency Training Program of disruptive behavior in a non-retaliatory Contract, GME House Staff Manual, Postdoctoral environment Handbook, Student Handbook, Staff Handbook, - implementing the necessary actions to reme- By-Laws of the Medical and Dental Staff, Rules dy disruptive behaviors and Regulations of the Medical and Dental Staff,

What is EMTALA?

The Emergency Medical Treatment and Labor treatment to individuals with an emergency Act (EMTALA) is also known as the patient medical condition without consideration of the anti-dumping statute. This federal statute sets individual’s insurance coverage or ability to pay. the rules for providing medical services and

5 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT What Constitutes Harassment?

Harassment is doing or saying things that make • Making sexual comments about someone’s a person feel uncomfortable. Harassment can be clothing, body, appearance, or personal life based on race, color, religion, sex, sexual orienta- • Staring in a sexually suggestive or offensive manner tion, gender and/or gender identity or expression, • Any other uninvited comments, conduct, or be- marital or parental status, national origin, ethnicity, havior about someone’s sex, gender, or sexual citizenship status, veteran or military status, age, orientation disability, and any other legally protected basis. The above list provides just a few examples of sexual Examples of sexual harassment may include the harassment, but harassment in general can be de- following: fined as any verbal or physical behavior that creates • Inappropriate or uninvited promise of something a hostile work environment, and should immediately in exchange for a sexual favor (e.g., a promotion) be reported to your supervisor or Human Resources. • Telling lewd jokes or making sexual references or gestures For additional guidance, please refer to the harass- • Unwelcome touching or fondling ment policies in the manual and documentation • Sharing, sending, or displaying sexually inap- applicable to your position in the NYU Langone propriate images, videos, emails, or notes Community.

EMERGENCY CARE (EMTALA)

If you are in a role working with patients, you are care facilities who request a medical screening expected to comply with NYU Langone’s EMTALA examination, or whose appearance or behavior Policy on Screening, Stabilization, and Transfer of indicates that they are in need of emergency Individuals with Emergency Medical Conditions. care. You should not discourage such individuals To uphold this policy, you have a responsibility to: from getting emergency care at the facility where • Honor patients’ rights to receive medical you work or redirect them to another facility. screening examinations, and, if necessary, • Help secure medical transport to an emer- stabilizing treatment, by qualified medical pro- gency department for individuals who come to fessionals. Patients have this right even if they an off-campus site requesting treatment for an cannot pay and do not have insurance. They are emergency condition. also entitled to these services regardless of race, • Make sure medical screening examinations color, religion, sex, sexual orientation, gender and stabilizing treatments are not delayed and/or gender identity or expression, marital or while inquiring about payment method, obtain- parental status, national origin, ethnicity, citi- ing payment, or checking on insurance status. zenship status, veteran or military status, age, • Arrange appropriate transfer to another medical disability, diagnosis, or socioeconomic status. facility for patients who cannot be treated at NYU • Come to the aid of individuals at any of Langone’s emergency care services or urgent care NYU Langone’s emergency services or urgent facilities because of their capability or capacity.

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 6 PHARMACEUTICALS, PRESCRIPTION DRUGS, & CONTROLLED SUBSTANCES

If you have responsibility for, or access to, pre- take particular care to keep drugs secured at all scription drugs, controlled substances, over-the- times and be sure they are never available to or counter drugs, or any street-valued medical sup- provided to anyone who does not have a valid plies (for example, needles), you have a duty to: order from a provider licensed by the State of • Follow the laws, regulations, policies, proce- New York to write prescriptions. Controlled sub- dures, and standards that apply to your re- stances must be secured at all times. sponsibilities. You should become familiar with • Report security problems. If you are aware of, or the laws, internal policies, and Patient Care and suspect, a lapse of security or the inappropriate Nursing Standards that govern your work with distribution, handling or diversion of drugs, you these drugs and supplies, including but not limited must report it immediately to your supervisor, to the handling of waste, outdated, deteriorated, or Security, the Office of Compliance directly, or via unusable drugs. the confidential Compliance Helpline or online • Keep all drugs and supplies secure. You should Compliance intake form as described on page 18.

ENVIRONMENTAL HEALTH & SAFETY

NYU Langone has safety and health policies and remediate, transport, and/or dispose of hazard- procedures to ensure that patients, students, faculty, ous materials and conditions. employees, visitors, and the environment are protect- • Accurately maintain the records required by ed from undue health risks and unsafe conditions. To federal and state laws and regulations. maintain these safety standards, we must all: • Report suspected violations. If you suspect a • Comply with laws, regulations, and policies violation of an environmental or occupational regarding the shipping, handling, use, storage, safety or health law, or an unsafe condition, you transportation, and disposal of all hazardous must report it immediately to your supervisor materials, including radioactive materials and or Environmental Health and Safety, the Office medical or chemical wastes. of Compliance directly, or via the confidential • Handle and dispose of hazardous materials Compliance Helpline or online Compliance legally and appropriately, if you have responsi- intake form as described on page 18. bilities that include handling and/or disposing • If you work in extended care and rehabili- of such materials. tation, senior housing, adult day care, child • Comply with NYU Langone’s permits that allow day care and/or other community service for the safe management of waste discharge. facilities you should comply with the safety • Contract only with reputable, and where ap- standards for your specific patient, client, or plicable, licensed vendors to evaluate, monitor, resident populations.

7 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT LAWS, REGULATIONS, & NYU LANGONE HEALTH SYSTEM POLICIES

All members of the NYU Langone Community and Administrative Policy and Procedures Manual. must obey the letter and spirit of the laws, regu- Many of our organization-wide policies can be lations, and policies that are applicable to them. found via NYU Langone’s Policies and Procedures Each person has a responsibility to: intranet site at atnyulmc.org. You should also learn • Familiarize yourself with the laws and regula- and follow the policies and procedures within your tions that relate to your position and facility, own department. and uphold both the written words and the • Ask questions. If you have questions about meaning behind those words. laws, regulations, and policies or your responsi- • Maintain any licenses and/or credentials re- bilities to them, you should ask your supervisor, quired for your position. Human Resources, the Office of Compliance, or • Familiarize yourself with and avoid the actions the Office of Legal Counsel. that constitute professional misconduct if you • Inform NYU Langone if you become excluded are a licensed professional governed by a New from participating in federal or state healthcare- York State board. programs. NYU Langone receives money from the • In addition to this Code of Conduct, learn and federal and state government agencies, including comply with NYU Langone’s policies that relate entities such as Medicare, Medicaid, Tricare, and to your position. These policies are included in the National Institutes of Health. Because we our mission, values, By-laws of the Medical and receive these funds, we cannot employ or contract Dental Staff, Rules and Regulations of the Medical with anyone excluded from participating in a pro- and Dental Staff, GME House Staff Manual, Faculty gram funded by the federal or state government. Handbook, Residency Training Program Contract, If you learn that you have become excluded, you Postdoctoral Handbook, Student Handbook, Staff must contact the Office of Compliance directly to Handbook, Patient Care and Nursing Standards, inform NYU Langone of your exclusion.

What Constitutes Professional Misconduct?

According to the Office of Professional Miscon- • Being convicted of a crime duct, examples of misconduct include but are not • Failing to return or provide copies of a record limited to: on request • Engaging in acts of gross incompetence or • Being sexually or physically abusive gross negligence on a single occasion or more • Abandoning or neglecting a patient in need of than one occasion immediate care • Permitting or aiding an unlicensed person to • Performing unnecessary work or unauthorized perform activities requiring a license services • Refusing to provide services because of race, • Practicing under the influence of alcohol or creed, color, or national origin other drugs • Practicing beyond the scope of the profession • Releasing confidential information without For all other licensed professionals, refer to the authorization relevant governing board.

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 8 What Does it Mean to be “Excluded”?

An exclusion disallows participation in Medicare, • Conviction related to patient abuse Medicaid, and all federal healthcare programs. • Conviction of a crime related to federal or state Excluded individuals and their employer cannot healthcare programs receive payment for items and services directly or • Submitting claims for excessive charges, unnec- indirectly derived from federal healthcare programs. essary services, or services that fail to meet professionally recognized standards of healthcare Examples of situations that can result in be- coming excluded include but are not limited to: An exclusion remains in force until an official rein- • Default on a health education loan or scholarship statement has been granted by the State or Federal • License revocation or suspension Office of Inspector General for participation in Medi- • Felony conviction related to healthcare fraud care, Medicaid, and any federal healthcare programs. • Felony conviction related to a controlled substance

RESPONSIBILITIES OF MANAGERS & SUPERVISORS

If you have management or supervisory responsi- strating your understanding of and compliance bility, you have an additional duty to: with laws and regulations. • Make a diligent effort to keep up with reg- • Ensure that departmental policies and stan- ulatory changes that affect your areas of dards are complete and up-to-date. responsibility by reviewing professional jour- • Make sure your department obtains all nec- nals, listservs and other publications, and online essary licenses, permits, and approvals required resources. for operation. • Seek out both internal and external profes- • Support all regulatory initiatives including en- sional development opportunities. suring that all required education and training • Act as a role model for your staff, demon- is completed.

9 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT ANTI-KICKBACK & PHYSICIAN SELF-REFERRAL

We prohibit our employees and service providers or indirectly, in exchange for referring patients. from soliciting, receiving, offering or paying anything • Not demand or expect anything in return for of value in exchange for referring patients, products, referring business. If you are in a position to or services. If you accept or make referrals, you must: make referrals to another healthcare provider, • Adhere to NYU Langone guidelines on you will not take into account the volume or accepting referrals. If you are in a position to value of referrals that the provider has made, or accept patient referrals and admissions, you may make, to NYU Langone. must do so based solely on the patient’s medi- • Learn the rules that apply to the Stark law cal needs and our ability to render the services that governs physician self-referrals for Medi- needed. You should never offer anything of val- care and Medicaid patients. ue, directly or indirectly, to physicians or anyone • Not refer patients for “designated health else in exchange for referral of patients. services” to a facility that you have an owner- • Adhere to guidelines on making referrals. If ship interest in, or compensation arrangement you are in a position to make referrals, you will with, if services are being paid for by Medicare not solicit or receive anything of value, directly or Medicaid, unless a specific exception applies.

What Are “Designated Health Services”?

The following have been identified by the Centers for • Durable medical equipment and supplies Medicare and Medicaid Services (CMS) as “designated • Parenteral and enteral nutrients, equipment, health services” under the Stark law and regulations: and supplies • Clinical laboratory services • Prosthetics, orthotics, and prosthetic devices • Physical therapy services and supplies • Occupational therapy services • Home health services • Outpatient speech-language pathology services • Outpatient prescription drugs • Radiology services • Inpatient and outpatient hospital services • Radiation therapy services and supplies

ACCURATE & TRUTHFUL DOCUMENTATION

If you are responsible for documentation, finan- responsible for. cial reporting, or coding and billing, you should • Ensure that the financial transactions you report perform your duties accurately, truthfully, and reflect actual transactions and conform to Gener- promptly. You have a duty to: ally Accepted Accounting Principles (GAAP). • Create and maintain thorough, accurate records. • Accurately record all funds, assets, liabilities, You should promptly document records as required revenues, and expenses and avoid financial re- by your job, following legal requirements, ethical porting practices that may be considered fraud, professional standards, and departmental policies. such as the following: • Fairly and accurately represent the financial - Hiding expenditures, funds, assets, or liabilities condition of NYU Langone or any area you are - Knowingly providing false or inaccurate

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 10 information to an employee, management, • Avoid coding practices that may be considered auditors, legal counsel, government agencies, fraud or abuse, such as the following: or accreditation organizations - Using “default codes” or selecting codes - Providing untrue statements of material fact because they guarantee payment, instead of or omitting material facts coding and billing the products and services - Intentional apportioning of incorrect costs on actually provided reports - “Upcoding,” or selecting the code for a more • Produce cost reports that are true, correct, and serious diagnosis or more extensive proce- complete, and prepared in accordance with regu- dure than is actually performed latory requirements. - “Unbundling” a group of procedures and • Take responsibility. If coding or billing is done on coding them separately in order to receive a your behalf, you should have a thorough knowl- separate payment for each procedure, when edge of the claims and verify that they are accu- one or more are components of a global code rate. You should never sign a document without - Billing for medically unnecessary services being certain it is accurate. - Cutting and pasting or copying forward the • Bill Medicare, Medicaid, and commercial payors history of present illness, exam, or medical de- only for services that are medically necessary. cision making in the electronic health record • Comply with NYU Langone’s policy on Compli- • Immediately report any improprieties that you ance Concerns: Reporting, Investigating and may suspect in accounting, internal controls, Protection from Retaliation. or auditing to the Office of Compliance directly, • Follow all federal and state laws and regula- or via the confidential Compliance Helpline or tions including, but not limited to Anti-Kickback, online intake form as described on page 18. NY State and Federal False Claims Act, Stark, • Promptly report and return any identified over- and HIPAA laws. payments. • Only assign and report billing codes that are • Report any activity that involves the submis- clearly and consistently supported by docu- sion of fictitious or fraudulent claims. mentation in the health record.

INVESTIGATIONS, ACCREDITATIONS, SURVEYS, AUDITS, OR INQUIRIES

NYU Langone cooperates fully with requests from ing associations such as The Joint Commission governmental agencies, accrediting organizations, (including Standards for Long Term Care), and external auditors, and internal parties concerning the Commission on Accreditation of Rehabilitation our operations. We need everyone’s commitment to: Facilities (CARF) in an open and honest manner. • Uphold NYU Langone’s policy on Responding • Cooperate with all investigations, examinations, to Government Investigations. and audits from both internal and external parties. • Report any requests you receive from a govern- • Never destroy or alter records requested for an ment investigator to your supervisor, who will investigation, or provide untruthful or misleading contact the Office of Legal Counsel or the Office statements on or about those documents. of Compliance. • Never pressure or suggest to anyone to hide • Follow the guidance provided by the Office of information from, or provide false information Legal Counsel if you are asked to surrender to, government investigators, accreditation documents to external investigators. surveyors, internal parties, or external auditors. • Cooperate with representatives from accredit-

11 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT CONFIDENTIALITY & HIPAA PRIVACY

Every member of the NYU Langone Community is HIPAA intake form or the Office of Compliance responsible for safeguarding protected information directly as described on page 18. about patients, research subjects, employees, students, and the institution itself. We each have a duty to: If you work directly with patient information, you • Safeguard protected and confidential infor- have an additional duty to protect PHI as set forth mation to prevent disclosing it to anyone who in the Health Insurance Portability & Accountabil- does not have a business purpose to know. ity Act (HIPAA). You can comply with HIPAA by • Follow NYU Langone’s confidentiality and taking the following actions: security guidelines. Pay particular attention to • Encrypt all email containing PHI being sent the specific guidelines included in the following: to recipients outside NYU Langone, by using – Privacy, Information Security, and Confidenti- SendSafe secure email. ality Agreement • Securely dispose of equipment that contains – Workforce Members IT Policy PHI including but not limited to computers, – HIPAA Privacy Policies telephones, fax machines, and copiers by con- • Access protected information only to perform tacting Medical Center IT. your responsibilities and for no other purpose. • Properly dispose of paper that contains PHI • Limit use and disclosure of protected infor- by shredding it with cross cut shredders or mation to only that which is relevant to only placing in designated shredder bins. business or other intended purposes. • Provide physical safeguards to PHI by locking • Refrain from sharing competitive information or logging off your computer, not sharing your concerning NYU Langone with representatives passwords and changing them often, and lock- from other hospitals, healthcare providers, or ing your doors and drawers. medical schools. Among the classes of confi- • Only use mobile and portable devices equipped dential information you should not discuss are with NYU Langone encryption and data erasing the following: software to access NYU Langone data. – Business arrangements. Our financial and • Refrain from talking about PHI in public places. contractual arrangements with suppliers and • Not accessing PHI in the view of unautho- managed care companies. rized individuals. – Plans. Information about our strategic plans, • Only use a NYU Langone issued email ad- potential acquisitions, and planned investments. dress (e.g., @nyumc.org or @med.nyu.edu) to – Marketing. Our marketing efforts or future plans. conduct all NYU Langone business. – Financial information. Our prices, profession- • Not transporting PHI on unencrypted porta- al fees, reimbursements, and salary levels. ble devices and instead accessing PHI through • Comply with NYU Langone’s guidelines for atnyulmc.org, or if necessary, transporting PHI reporting breaches of Protected Health Infor- on a Medical Center IT issued encrypted flash mation (PHI). If you discover that unsecured drive (Iron Key). PHI has been accessed, used, or disclosed, or if • Not sharing patient information using text you find or receive PHI that you are not autho- messaging or social media. rized to have, you must immediately report the • Only use MCIT supported and authorized incident to the HIPAA Helpline at 877.PHI.LOSS communication methods when sharing PHI. (877.744.5677). It is multilingual, toll-free, and • Only access NYU Langone Information offsite available seven days a week, 24 hours a day. via webmail or the atNYULMC portal. You may also report the incident via the online

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 12 What is Protected Health Information (PHI)?

Protected Health Information (PHI) means individually • Addresses identifiable health information that is transmitted or • Certificate/license numbers maintained in any form (oral, electronic, paper) that: • Telephone numbers • Identifies or could be used to identify an individual • Vehicle identifiers • Is created or received by a healthcare provider, • Fax numbers health plan, employer, or healthcare clearinghouse) • Biometric identifiers And relates to the: • Social security numbers • past, present, or future physical or mental • Device identifiers & serial numbers health or condition of an individual • Medical record numbers • provision of healthcare to an individual • Web URLs • past, present, or future payment for the provi- • Health plan numbers sion of that healthcare • IP address • Account numbers Examples of PHI include but are not limited to: • Email addresses • Names • Dates (admission, discharge, etc.) • Photos • Other unique identifiers

What is HIPAA Privacy? What is HIPAA Security?

The HIPAA Privacy Rule governs how NYU Langone The HIPAA Security Rule governs the protection uses and discloses PHI and provides patients with of PHI in electronic form and requires implemen- rights related to their health information. tation of administrative, physical, and technical safeguards to protect PHI.

PROTECTION AND USE OF NYU LANGONE’S ASSETS

Every member of the NYU Langone Community is as well as office, medical, cleaning, and food responsible for protecting NYU Langone’s assets supplies. from loss, damage, theft, misuse and waste. These • Departmental funds - If you are in a supervisory assets include: or management position, you will maintain careful • Time - You will work productively and report internal controls and accurate records of depart- your time and attendance accurately. mental funds, including cash and cash equivalents. • Equipment and supplies - You will not remove You will exercise appropriate oversight of financial NYU Langone’s supplies and equipment from the reports, expense accounts, and timesheets. premises for personal use. These supplies and • Records - You will comply with all record reten- equipment include vehicles, machinery, tools, com- tion and destruction policies and schedules that puters, printers, telephones, and medical devices, apply to your job responsibilities.

13 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT POLITICAL PARTICIPATION

NYU Langone’s funds, time, and equipment correspondence electronically. should not be used for political activity of any • Use your own funds for any political partici- kind, including campaigning for (or against) pation and do not attempt to be reimbursed a political candidate. Participation in political by NYU Langone. This includes contributions campaigns could jeopardize NYU Langone’s through professional organizations to Political tax-exempt status. This can be prevented by each Action Committees (PACs). member of the NYU Langone Community com- • Refrain from providing or offering any ben- plying with the following guidelines: efit in an attempt to influence government • Participate in political activity only as a officials. If you are responsible for conducting private citizen, not as a representative of transactions or handling contracts with govern- NYU Langone. You are entitled to participate mental agencies, you should ensure that they in, or contribute to, any political organization are handled honestly and ethically. or campaign you choose. However, you will • Report inappropriate requests for benefits. clearly label any personal communication with If a government representative requests or de- legislators as your own, not as correspondence mands any type of benefit from NYU Langone, coming from NYU Langone, and cannot use you should report it immediately to the Office of your NYU Langone email address if sending Compliance or the Office of Legal Counsel.

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 14 CONFLICTS OF INTEREST

We have a duty to avoid situations in which - Employees involved in purchasing decisions our business or personal interests influence (or on behalf of NYU Langone appear to influence) our ability to act in the best - Members of any oversight committees related to interest of NYU Langone. If you believe you have patient care, purchasing, research, or education a conflict of interest, you should disclose it. You - All employees of the Offices of Compliance, also have a responsibility to: Legal Counsel, Government Affairs, and • Learn to recognize conflict of interest situations. certain NYU Langone Office of Science and • Submit an annual disclosure if you are one of Research Staff the following: - Any other member of the NYU Langone Com- - Paid faculty (full or part-time) munity who may have a conflict of interest - Chairs, vice chairs, vice presidents, deans, as- • Refuse personal gifts or benefits from vendors, sociate and assistant deans, and department/ patients, or others. NYU Langone’s Gift Policy in- division administrators cludes guidelines about the acceptance and/ or so- - Director-level and above employees licitation of gifts or benefits from vendors, patients, - Investigators and all other key personnel and others for an inappropriate use or purpose. on grants; investigators, co-investigators, • Never use your position to profit personally sub-investigators, and research coordinators or to assist others in profiting at the expense of on IRB applications NYU Langone.

What Should I do if I Think I Have a Potential Conflict of Interest?

You must immediately notify the Conflicts of Interest informed of any laws and regulations related Management Unit for further guidance on how to to conflicts of interest in research. Education is formally disclose this information for review and eval- available via the Conflicts of Interest Manage- uation. The Conflicts of Interest Management Unit ment Unit and external resources. can be reached at [email protected]. • Disclose any financial interests and/or relationships related to Sponsored Programs that you, If you are a research investigator or other research or your immediate family members, have with team member involved in research at NYU Langone any entity that may reasonably appear to affect campuses, you have an obligation to conduct research or be affected by the design, conduct, or report- that is free from any appearance of impropriety or ing of the research. conflict of interest. You also have a responsibility to: • Adhere to any stipulations issued in relation to • Perform research with objectivity and trust- research that have been implemented to man- worthiness that maintains the integrity of the age any potential conflicts of interest that may research, as well as the institution, and is in the exist. All potential conflicts of interests must best interest of the subjects enrolled in the study. be evaluated, and managed and/or eliminated • Understand the Policy on Conflicts of Interest under the Policy on Conflicts of Interest in Re- in Research and Sponsored Programs and stay search and Sponsored Programs.

15 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT How Can I Recognize a Conflict of Interest Situation?

You may have a conflict of interest if you or a You may also have a conflict of interest if you member of your immediate family is an owner, a have the authority to recommend doing business part-owner, or an employee of—or is receiving with an NYU Langone vendor or contractor and money from—a company that: a member of your immediate family is an owner, • does business with NYU Langone a part-owner, or an employee of—or is receiving • proposes to do business with NYU Langone money from—that vendor or contractor. • competes with NYU Langone • solicits employees from NYU Langone

Why Should I Submit an Annual Disclosure?

The Policy on Conflicts of Interest in Business to the Conflicts of Interest Management Unit. Affairs requires certain members of the NYU Lan- This requirement helps to ensure that NYU Lan- gone community to submit an Annual Disclosure gone’s mission is carried out with integrity.

SCIENTIFIC & CLINICAL RESEARCH

NYU Langone is committed to developing and complying with the many administrative and conducting research with the highest ethical stan- fiscal requirements for government-spon- dards. If you are involved in research, you have a sored research as well as research sponsored responsibility to produce work that is consistent by industry and non-profit organizations with federal, state, and local laws and regulations, - Office of Clinical Trials (OCT), which facili- as well as NYU Langone policies, and to: tates the conduct of clinical research studies, • Obtain all required approvals and follow all such as contract and budget negotiations NYU Langone guidelines, policies, and proce- and business development dures, including those of the following: • Submit accurate, truthful, and complete ac- - Institutional Review Board (IRB), for approval counting, record keeping, and billing records. of all research involving human subjects • Comply with governmental and sponsor - Institutional Animal Care and Use Committee requirements, as well as NYU Langone policies (IACUC), for approval of all research involv- and procedures including those relating to: ing animals – Clinical Research and Billing - Institutional Bio-Safety Committee (IBC), for – Cost Transfers on Sponsored Projects approval of all research involving recombi- – Institutional Cost Sharing nant DNA and highly infectious agents – Effort Reporting for Sponsored Research - Dual Use of Research Concerns (DURC) for Projects approval of all research involving select agents – Program Income Earned on Sponsored Proj- - Embryonic Stem Cell Research Oversight ects Committee (ESCRO) for approval of research – Charging Direct Costs to Sponsored Projects involving human embryonic stem cells • Never participate in research misconduct by - Sponsored Programs Administration (SPA) fabricating, falsifying, or plagiarizing results. and Research Finance (RF), for guidance on

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 16 Which Compliance Areas Are of Particular Importance to Researchers?

Our top priorities are . . . to ensure that the federal government, state • Protecting individuals and upholding their government, and other sponsors are charged rights during clinical trials and other research in only for what they have agreed to pay for and which they participate. for the work we have actually performed. • Fully informing research participants of their • Good clinical practice. Researchers must receive rights and responsibilities, risks, expected bene- certification of training and education in good fits, and alternatives. clinical practice as a prerequisite to conducting • The humane care and use of laboratory animals research with human subjects by completing in biomedical and behavioral research and edu- the required IRB tutorials. cation. • Principles for managing research data. In accordance with HIPAA rules, researchers are In addition, researchers need to be especially responsible for the privacy and security of their familiar with: research data. Transfer of research data from • Administrative responsibilities that are needed NYU requires approval.

17 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT RESPONSIBILITY FOR REPORTING

Compliance is the responsibility of every member The Compliance Helpline is multilingual, toll- of the NYU Langone Community. If you suspect free, and available seven days a week, 24 hours violations of the Code, NYU Langone policies, or a day. Calls are answered by an outside service. federal, state, or local laws, you must immediately You do not need to reveal your identity and can report it using one of the following methods, even request that your report remain confidential. if you are not sure it is a true violation: You should give enough specific information • Make a report to your supervisor. Make an to enable a complete investigation of the issue appointment so you can discuss the issue you are reporting. In some instances, your confidentially and thoroughly. Be prepared to identity might need to be revealed in order for present any evidence you have to support your an investigation or legal proceeding to move allegations. forward. Whether your report is anonymous • Make a report to a representative from the or not, your compliance concern will only be Office of Compliance, Human Resources, or shared with others who have a need to know in the Office of Legal Counsel. If you are uncom- order to conduct an effective investigation and fortable talking with the person who supervis- to determine an appropriate course of action. es your work, you can contact any one of the • Make a report in writing. Send a description of following areas: your concern by letter, memo, or fax to: - Compliance Office: 212.404.4079 NYU Langone Medical Center - Compliance Email: [email protected] Office of Compliance - Compliance Intake Form: compliancenyul- One Park Avenue, 3rd floor mc.alertline.com/gcs/welcome New York, NY 10016 - Compliance Helpline: 866.NYU.1212 Confidential Compliance Fax: (May be anonymous) 212.404.4041 - HIPAA Helpline: 877. PHI.LOSS or 877. 744.5677 Failing to report a violation is a violation in itself. - Online HIPAA Intake Form: incidentform. If you know of, or suspect, a violation and do not com/HIPAA.nyulmc.jsp report it, you can face disciplinary action. - Human Resources Department—Employee Relations: 212.404.3857 - Office of Legal Counsel:212.404.4075 - Patient Relations: Tisch: 212.263.6906 HJD: 212.598.6336 Lutheran: 212.630.7310

NYU LANGONE MEDICAL CENTER CODE OF CONDUCT 18 NYU LANGONE HEALTH SYSTEM’S NON-RETALIATION POLICY

All members of the NYU Langone Community are may also be subject to legal claims by the individ- protected from retaliation if in good faith and with rea- uals about whom the bad faith reports were made. sonable belief, you report violations of this Code, NYU Langone policies, or federal, state, and local laws. Examples of retaliation include but are not limited to termination of employment, unjustified negative There will be no retaliation against you if in your performance reviews, harassment, or exclusion reasonable belief you raise concerns or questions from department meetings or social activities. about misconduct or report violations of this If you report a violation and believe you are Code, NYU Langone policies, or federal, state, and experiencing retaliation, you have the right to local laws. Reported compliance concerns are con- report this situation to the Office of Compliance or sidered to be made in bad faith if they are report- Human Resources. Anyone who retaliates against ed maliciously (with ill intent) or with reckless dis- someone who has raised a concern or reported a regard for their truth or falsity. Individuals making violation of the Code will be subject to disciplinary reports in bad faith may be subject to disciplinary action, including possible termination. or other employment action by NYU Langone and

DISCIPLINARY ACTION

Violations of this Code, NYU Langone policies, or Medical and Dental Staff, Rules and Regulations federal, state, and local laws, could lead to serious of the Medical and Dental Staff, Patient Care and disciplinary action. Nursing Standards, and the Administrative Policy and Procedures Manual). Any member of the NYU Langone Community who violates this Code of Conduct, will be subject Examples of actions subject to disciplinary ac- to disciplinary action, up to and including termi- tion specific to this Code include the following: nation. The specific disciplinary action will depend • Participating in activities that violate this Code on the nature and severity of the violation. Disci- • Encouraging, directing, facilitating, or permitting plinary actions will be consistent with the manual activities that violate this Code and documentation applicable to your position in • Failing to report suspected violations of this Code the NYU Langone Community (i.e. Faculty Hand- • Failing to detect violations of this Code that book, Residency Training Program Contract, GME should have been discovered in the course of House Staff Manual, Postdoctoral Handbook, Stu- your supervisory or management responsibilities dent Handbook, Staff Handbook, By-Laws of the

19 NYU LANGONE MEDICAL CENTER CODE OF CONDUCT NYU LANGONE MEDICAL CENTER CODE OF CONDUCT